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Ghana has committed politically, legislatively, and fiscally to providing universal health insurance coverage for its population with the intent of reducing financial barriers to utilization of health care.. However, under current cost and enrollment projections the system will not be financially sustainable in the long term, so there is more work to do. This book provides an important evidence-based review of the current performance of Ghana's health system and options for reform. As such, it provides an overall picture of the Ghana health sector, how things were and how things have changed, as well as a situational analysis of the performance of the health delivery and health financing systems using the latest available data. Finally, it discusses key reform issues and options in the context of the country's likely fiscal space. An important and valuable contribution of this book is its examination of how Ghana is performing compared to its neighboring countries and compared to other countries with similar incomes and health spending, providing global benchmarks for Ghana's health system performance.

Abstract This is a methodological study for the development and validation of the Multidimensional Instrument for Evaluating of the Implementation of Psychosocial Care Network (IMAI-RAPS) in Minas Gerais (MG)/Brazil. The study was carried out in three stages: evaluability study, development of the IMAIRAPS, application of the Delphi Technique for content and appearance validation of the questions. The analysis of official documents, literature review and a structured engagement with program members were carried out to clarify its operationalization and focus on the central aspects to be evaluated. A theoreticallogical model of RAPS was built according to the Donabedian triad: structure, process and result and organized into: Minimum Units (Mental Health Care and Psychosocial Rehabilitation), Connectivity (Network Articulation), Integration (Governance and Management of the Care), Normativity (Mental Health Policy and Participation and Social Control), Subjectivity and Structure (Services, Logistics System and Health Education). The IMAI-RAPS was derived from this model, which was validated by 44 experts in the field, indicating the approach of relevant, useful and viable questions for evaluating the structure and process of implementing the program in MG. The use of the Delphi Technique made it possible for the developed products to be marked out by Psychosocial Care Network scholars or professionals from different regions of the country, increasing the analytical power of the tool. Resumo Trata-se de um estudo metodológico para desenvolvimento e validação do Instrumento Multidimensional para Avaliação da Implantação da RAPS (IMAI-RAPS) em Minas Gerais (MG)/Brasil. O estudo foi executado em três etapas: estudo de avaliabilidade, desenvolvimento do IMAI-RAPS, aplicação da Técnica Delphi para validação de conteúdo e aparência das questões. Foram realizados a análise de documentos oficiais, revisão da literatura e um engajamento estruturado com membros do programa para esclarecer sua operacionalização e focalizar os aspectos centrais a serem avaliados. Um modelo teórico-lógico da RAPS foi construído de acordo com a tríade donabediana: estrutura, processo e resultado e organizado em: Unidades Mínimas (Assistência à Saúde Mental e Reabilitação Psicossocial), Conectividade (Articulação da Rede), Integração (Governança e Gestão do Cuidado), Normatividade (Política de Saúde Mental e Participação e Controle Social), Subjetividade e Estrutura (Serviços, Sistema Logístico e Educação em Saúde). Desse modelo derivou-se o IMAI-RAPS que foi validado por 44 experts da área indicando a abordagem de questões relevantes, úteis e viáveis para avaliação da estrutura e processo de implantação do programa em MG. A utilização da Técnica Delphi possibilitou que os produtos desenvolvidos fossem balizados por estudiosos ou profissionais da RAPS de diversas regiões do país aumentando o poder analítico da ferramenta.

Abstract The present study aims at analyzing the regionalization of the services carried out by the Psychosocial Care Network (RAPS in Portuguese) in the state of Minas Gerais (MG) in Brazil, yielding indicators that may enhance the SUS strategic management towards the strengthening of the psychosocial care provided by the state. It is a cross-sectional study, based on the data collected in May 2019 from government websites, considering the state’s Macro-Regions and Health Regions as units of analysis. Indicators of service coverage in relation to the population in accordance to normative parameters determined by the Ministry of Health for a better understanding of the effective coverage were produced, and a general indicator (iRAPS) of the supply of services in this network in Minas Gerais state was validated. The outcomes allow a detailed analysis of the structural aspect of the RAPS in MG and unveil the development of a robust network. However, important regional heterogeneities were noticed and also a lack of services aiming at specific populations providing assistance 24 hours a day, which weakens the proper access to RAPS in several parts of the state. Higher values of iRAPS were found in health regions with low socioeconomic development and low general offer of health services, a fact that differs from the national scenario, which may imply state policy investments aiming at offering RAPS within the state hinterland areas. Resumo Objetivou-se analisar a regionalização dos serviços da Rede de Atenção Psicossocial (RAPS) em Minas Gerais (MG), Brasil, gerando indicadores que possam potencializar a gestão estratégica do SUS no fortalecimento da atenção psicossocial do estado. É um estudo transversal, realizado a partir de dados coletados em maio de 2019 em sites governamentais, tendo as Macrorregiões e Regiões de Saúde do estado como unidades de análise. Foram produzidos indicadores da cobertura de serviços em relação à população, de acordo com parâmetros normativos estipulados pelo Ministério da Saúde, para melhor compreensão da cobertura efetivada e validou-se um indicador geral (iRAPS) da oferta dos serviços dessa rede em MG. Os resultados encontrados possibilitam uma análise detalhada do aspecto estrutural da RAPS em MG e demonstram a implantação de uma rede robusta. Entretanto, percebem-se importantes heterogeneidades regionais e também uma carência de serviços voltados para populações específicas e com funcionamento 24 horas, o que fragiliza o adequado acesso à RAPS em diversos territórios do estado. Foram encontrados maiores valores do iRAPS nas regiões de saúde com baixo desenvolvimento socioeconômico e baixa oferta geral de serviços de saúde, fato que difere do cenário nacional.

BackgroundCommunity health worker (CHW) programmes, when adequately integrated into mainstream health systems, can provide a viable, affordable and sustainable path to strengthened health systems that better meets demands for improved child health, especially in resource-constrained settings. However, studies that report on how CHW programmes are integrated into respective health systems in sub-Saharan Africa (SSA) are missing.AimThis review presents evidence on CHW programmes’ integration into National Health Systems for improved health outcomes in SSA.SettingSub-Saharan Africa.MethodSix CHW programmes representing three sub-Saharan regions (West, East, and Southern Africa) were purposively selected based on their deemed integration into respective National Health Systems. A database search of literature limited to the identified programmes was then conducted. Screening and literature selection was guided a scoping review framework. Abstracted data were synthesised and presented in a narrative form.ResultsA total of 42 publications met the inclusion criteria. Reviewed papers had an even focus on all six CHW programmes integration components. Although some similarities were observed, evidence of integration on most CHW programme integration components varied across countries. The linkage of CHW programmes to respective health systems runs across all reviewed countries. Some CHW programme components such as CHW recruitment, education and certification, service delivery, supervision, information management, and equipment and supplies are integrated into the health systems differently across the region.ConclusionDifferent approaches to the integration of all the components depict complexity in the field of CHW programme integration in the region.ContributionThe study presents synthesized evidence on CHW programmes integration into national health systems in SSA.

The Basic Health Care Provision Fund (BHCPF) under Nigeria’s National Health Act (NHA) includes the establishment of a national emergency medical response service. This study evaluated the early implementation process of this service as perceived by key stakeholders, which is essential for sustainability and scalability. This cross-sectional mixed-methods study was conducted among national and state-level stakeholders involved in early implementation. Data collection included a self-designed knowledge assessment of national and international emergency care guidelines and a semi-structured open-ended interview adapted from the Consolidated Framework for Implementation Research (CFIR). Qualitative data were analyzed using a deductive framework approach, with construct ratings assigned by consensus. Inter-rater reliability was assessed using Cohen’s kappa. Associations between knowledge scores and CFIR construct ratings were explored using Spearman’s rank correlation. Eight stakeholders from three states with active implementation participated. Respondents expressed strong agreement regarding the source of innovation, tension for change, and available resources, reflecting broad recognition of the need for innovation. Notable variability was observed in goals and feedback, and in available resources, with narrative differences across states. Knowledge assessment scores varied widely (median 60%). A strong positive association was observed between knowledge scores and ratings of goals and feedback (ρ = 0.743, p  = 0.035), although findings are exploratory given the small sample size. Early implementation of Nigeria’s emergency medical response system is characterized by strong stakeholder motivation but uneven knowledge, resource availability, and goal-feedback mechanisms. Targeted capacity-building, improved communication, and structured feedback processes may strengthen implementation and support future scale-up under the NHA.

Background In many universal health systems, waiting times act as a non-monetary rationing mechanism, one that should be based on clinical need rather than the ability to pay. However, there is growing evidence that among patients with similar levels of need, waiting times often differ according to socioeconomic status. The mechanisms underlying inequality in access remain unclear. Methods Using data for Spain, we study whether waiting times for primary and specialist care depend on patients’ socioeconomic status (SES). Additionally, we make use of the continuous nature of our data to explore whether the SES-related differences in waiting times found for specialist consultations vary among different points of the waiting time distribution. Results Our results reveal the presence of a SES gradient in waiting times for specialist services explained on the basis of education, employment status and income. In addition, for primary care, we found evidence of a slightly more moderate SES gradient mostly based on employment status. Furthermore, although quantile regression estimates indicated the presence of a SES gradient within the distribution of waiting times for specialist visits, the SES differences attenuated in the context of longer waiting times in the public sector but did not disappear. Conclusion Our findings suggest the principle of equal treatment for equal need, assumed to be inherent to national health systems such as the Spanish system, is not applied in practice. Determining the mechanism(s) underlying this selective barrier to healthcare is of crucial importance for policymakers, especially in the current COVID-19 health and economic crises, which could exacerbate these inequalities as increasing numbers of treatments are having to be postponed.

Background The Spanish National Health System (NHS) faces a significant shortage of clinical psychologists with only 5.58 per 100,000 inhabitants. This study aimed to estimate the required number of specialists and residents in Clinical Psychology to provide adequate psychological treatments to the population in the NHS. Methods A needs-based model was adapted to forecast the required total number of clinical psychologists and the annual increase in the positions of residents in Clinical Psychology (PIR). This model followed five steps: (1) obtaining Spanish prevalence rates for three broad mental disorder categories (depression, anxiety, and others or severe mental disorders) from the 2017 National Health Survey (ENSE); (2) multiplying the prevalence rates by the Spanish population aged ≥ 15 years; (3) defining the percentage of cases eligible for treatment under three predefined scenarios (protocolized, intermediate, and adjusted); (4) operationalizing the characteristics of the three treatment scenarios (session number and duration); and (5) calculating the total number of clinical psychologists and the annual increase required for PIR positions. Results Depending on the treatment scenario, the estimations show a need for clinical psychologists ranging from 1665 to 13,527 for treating depressive disorders, 1792–9799 for anxiety disorders, and 2074–8294 specifically for severe mental disorders. On the other hand, depending on the treatment scenario and the timeframe to achieve the estimated number of professionals (within 3, 5, 8, or 10 years), for example, to achieve those estimations of professionals within 3 years, and according to the adjusted treatment scenario, the Spanish health system should offer approximately 481 PIR positions yearly during 3 years. Conclusions A significant increase in the number of PIR positions is necessary to meet the growing demand for psychological treatment in the Spanish NHS. Investing in a mental-health workforce can lead to substantial health and economic benefits. This study provides valuable insights for workforce planning and highlights the importance of addressing the shortage of clinical psychologists in the NHS.

The third United Nations Sustainable Development Goal promotes health and well-being. Despite the existence of academic literature examining the relationship between health and income inequality, evidence on the role of healthcare systems in this inequality remains limited. This article aims to analyse the extent to which healthcare systems are associated with differences in economic inequality. To this end, a balanced panel of 27 European Union countries for the period 2005–2022 is used, applying t-tests for differences in means and linear regression models using S80/S20, Gini and Palma inequality measures. The main results show that countries with a Social Health Insurance System (SHIS) exhibit, on average, lower levels of income inequality, despite not being the highest spenders on healthcare. On the other hand, healthcare expenditure has a negative and statistically significant relationship with inequality, whereas in countries with a Mixed Healthcare System (MHS), this association is not statistically significant. A disaggregated analysis of public and private spending indicates that public expenditure is particularly relevant in SHIS countries being negatively associated with income inequality, whereas this relationship differs in countries with a National Health System (NHS). Thus, it is concluded that healthcare systems display significant differences in the relationship under study.

Greece is the country of “Xenios Zeus”, the Ancient Greek god of foreigners and hospitality; however, it is also the main point of entry to Europe. Since the beginning of 2014, 1,112,332 refugees crossed the borders of Greece. Overall, 33,677 children and adolescent refugees sought asylum in Greece from 2013 to 2017, while 57,042 refugees are currently being hosted. The rapid entry of refugees into Greece raised the critical issue of health policy. The Greek National Health Service (NHS) faces many challenges. Adequate economic and human support is essential if this situation is to be managed successfully. However, Greece still bears the burden of the economic downturn since 2009. In fact, the crisis led to shortages in crucial equipment, and unmet health needs for both locals and refugees. The NHS deals with traumatic experiences, as well as cultural and linguistic differences. Overcrowded reception centers and hotspots are highly demanding and are associated with severe disease burden. This highlights the importance of guidelines for medical screening, healthcare provision, and a well-managed transition to definitive medical facilities. Furthermore, non-governmental organizations make an essential contribution by ensuring appropriate support to refugee minors, especially when they experience poor access to the NHS.

Introduction: Ensuring access to the right information at the right time can improve the safety, effectiveness and efficiency of care. A systematic and detailed collection of patient records, commonly known as electronic health records (EHRs), forms the core of the information system architecture in integrated health systems. Description: Since January 2021, seventeen years after the German legislation to implement EHRs (elektronische Patientenakte; ePA) came into force, the sickness funds in Germany have been offering their enrollees a downloadable application with which patients can access their personal EHRs through an electronic device. Looking at the ePA adoption process, it is now safe to argue that the deployment has been anything but successful. After two years of the launch, the number of ePA users amounts to not even 1% of the insured population in Germany, failing to move the needle on integrated care and health data integration. Based on a public policy theory, this article analyses the factors that are influencing the ePA implementation and secondary use of ePA data. Discussion: As the German experience shows, the feasibility of digital health projects depends on several contextual factors: countries with a high degree of self-governance and federal structures have to manage complex coordination processes that often slow down or otherwise impede digitalisation processes. In addition, cultural peculiarities such as concerns about data protection and security can be a hindering factor for digitalisation. Whereas the new German government and European initiatives such as the European Health Data Space (EHDS) create an advantageous situation for the ePA implementation and secondary use of health data, the structural and cultural issues in Germany should be acknowledged and tackled. Conclusion: Concerning the structural factors, a further reorganisation of the board of gematik, the key organisation of digital health solutions in Germany, should be considered. Cultural factors in Germany affect especially the secondary use of data; organising information campaigns, investing in (digital) health literacy of the population and designing a user-friendly ePA application are central in this context.   Zusammenfassung Einleitung: Der Zugang zu den richtigen Informationen zur richtigen Zeit kann die Sicherheit, Wirksamkeit und Effizienz der Gesundheitsversorgung verbessern. Eine systematische und detaillierte Sammlung von Patientenakten, bekannt als Electronic Health Records (EHRs), bildet den Kern der Informationssystemarchitektur in integrierten Gesundheitssystemen. Beschreibung: Seit Januar 2021, siebzehn Jahre nach Inkrafttreten der deutschen Gesetzgebung zur Einführung der elektronischen Patientenakte (ePA), bieten die Krankenkassen eine zum Download verfügbare Anwendung an, mit der Patienten über ein elektronisches Gerät auf ihre persönliche elektronische Patientenakte zugreifen können; bisher jedoch mit wenig Erfolg. Zwei Jahre nach der Inbetriebnahme beläuft sich die Zahl der ePA-Nutzer auf weniger als 1 % der gesetzlich versicherten Bevölkerung in Deutschland; es ist also nicht gelungen, die integrierte Versorgung und Datenintegration voranzutreiben. Basierend auf einer politikwissenschaftlichen Theorie, werden in dieser Studie Faktoren analysiert, welche die ePA-Einführung und die sekundäre Nutzung von ePA-Daten beeinflussen. Diskussion: Wie die Erfahrungen mit der ePA in Deutschland zeigen, hängt die Umsetzbarkeit digitaler Gesundheitsprojekte von einer Vielzahl von kontextuellen Faktoren ab: Länder mit einem hohen Maß an Selbstverwaltung und föderalen Strukturen müssen komplexe Koordinationsprozesse bewältigen, die den Digitalisierungsprozess oft verlangsamen oder anderweitig behindern. Darüber hinaus können kulturelle Eigenheiten wie Datenschutz- und Sicherheitsbedenken die Digitalisierung behindern. Obwohl die neue Bundesregierung und europäische Initiativen, wie der Europäische Gesundheitsdatenraum (European Health Data Space; EHDS), die ePA-Implementierung und die Sekundärnutzung von Gesundheitsdaten begünstigen, sollten strukturelle und kulturelle Probleme in Deutschland berücksichtigt und angegangen werden. Schlussfolgerung: Im Hinblick auf die strukturellen Faktoren sollte eine weitere Umstrukturierung der gematik, des wichtigsten Entscheidungsorgans für digitale Gesundheitslösungen in Deutschland, in Betracht gezogen werden. Kulturelle Faktoren in Deutschland beeinflussen vor allem die Sekundärnutzung von Daten; in diesem Zusammenhang sind das Organisieren von Informationskampagnen, die Förderung der (digitalen) Gesundheitskompetenz der Bevölkerung und die Gestaltung einer nutzerfreundlichen ePA-Anwendung von zentraler Bedeutung.   Schlüsselwörter: Elektronische Patientenakte; Akzeptanz von Innovationen; Verwaltung von Gesundheitsdaten; Integrierte Versorgung; Datenintegration; Nationales Gesundheitssystem; Deutschland